Falls and patterns of physical activity participation over 18 years in the Australian Longitudinal Study on Women’s Health

Objective To explore the relationship between long-term physical activity (PA) participation and falls. Methods Participants in the Australian Longitudinal Study of Women’s Health born 1946–1951 self-reported amounts of PA every 3 years since 1998 (mean age: 54 years, n=11 796). Latent class analysis described profiles of self-reported PA participation over 18 years. Associations between patterns of PA participation and self-reported falls measured in 2019 were examined using multinomial logistic regression adjusted for directed-acyclic graph-informed potential confounders, with the highly active group as the reference category. Results Women were grouped into five PA participation profiles. Compared with consistently highly active patterns (maintaining ≥300 min/week, 22%), consistently lower levels of PA<100 min/week (18%), consistently some PA<150 min/week (18%) and decreasing PA but maintaining≥150 min/week (n=3540, 30%) had higher odds of non-injurious falls (odds Ratiolower level (OR): 1.59, 95% CI 1.29 to 1.97; ORsome PA: 1.27, 95% CI 1.04 to 1.55; ORdecreasing activity:1.29, 95% CI 1.02 to 1.63) and injurious falls (ORlow level: 1.32, 95% CI 1.06 to 1.64; ORsome PA: 1.27, 95% CI 1.04 to 1.54; ORdecreasing activity: 1.47, 95% CI 1.18 to 1.83). No association was found between increasing PA (≥150 min/week, 11%) for non-injurious (OR 1.07, 95% CI 0.89 to 1.29) and injurious falls (OR 1.07, 95% CI 0.90 to 1.29). After adjusting for potential confounders, consistently lower levels of PA remained associated with increased non-injurious falls odds (OR1998 survey: 1.40, 95% CI 1.11 to 1.77; OR2016 survey: 1.35, 95% CI 1.07 to 1.71). Conclusion The increased odds of falls among women with consistently lower levels of PA over 18 years supports ongoing participation of 150+ min/week of PA.


Supplementary Table 1 Details of the variables collected in ALSWH and constructed in the directed acyclic graph (DAG)
Concepts / Node in the DAG

Variables included within the concepts
Information on how the data were collected in the survey Physical activity (Exposure) (1) Walking How many times did you walk briskly (for recreation or exercise, or to get from place to place) activity last week?Only count the number of times when the activity lasted for 10 minutes or more.
If you add up all the times you spent in each activity last week, how much time did you spend altogether in walking briskly (for recreation or exercise, or to get from place to place)?Moderate leisure activity How many times did you do moderate leisure activity (like social tennis, moderate exercise classes, recreational swimming, dancing) last week?Only count the number of times when the activity lasted for 10 minutes or more.
If you add up all the times you spent in each activity last week, how much time did you spend altogether doing moderate leisure activity (like social tennis, moderate exercise classes, recreational swimming, dancing)?Vigorous leisure activity How many times did you do vigorous leisure activity (that makes you breathe harder or puff and pant like aerobics, competitive sport, vigorous cycling, running, swimming) last week?Only count the number of times when the activity lasted for 10 minutes or more.
If you add up all the times you spent in each activity last week, how much time did you spend altogether doing vigorous leisure activity (that makes you breathe harder or puff and pant like aerobics, competitive sport, vigorous cycling, running, swimming) Falls (Outcome) Falls without injury (non-injurious falls), falls with injury (injurious falls) "In the last twelve months have you 1) had a fall to the ground; 2) been injured as a result of a fall; 3) needed to seek medical attention for an injury from a fall [Non-injurious falls, response 'Yes' to the statement 1) had a fall to the ground and 'No' to statements 2) been injured as a result of a fall; and 3) needed to seek medical attention for an injury from a fall] [Injurious falls, response 'Yes' to the statements 2) been injured as a result of a fall;  (2) For each question, please give the one answer that comes closest to the way you have been feeling.How much of the time during the past 4 weeks?
• Have you been a very nervous person • Have you felt so down in the dumps that nothing could cheer you up • Have you felt calm and peaceful • Have you felt down • Have you been a happy person [Response to the above statement: "All of the time" or "Most of the time" or "A good bit of the time" or "some of the time" or "A little of the time" or "None of the time"]

Loss of balance
In the last 12 months, have you had dizziness, loss of balance?[Responses: "Never" or "Rarely" or "Sometimes" or "Often"] SF36 Physical functioning (2) The following questions are about activities you might do during a typical day.Does your health now limit you in these activities?If so, how much?(ARIA+) (3) Accessed according to the remoteness of geographic classification and classified as "Major cities of Australia" or "Inner regional Australia" or "Outer regional Australia" or "Remote Australia" or "Very remote Australia"

Socioeconomic status
Education a What is the highest qualification you have completed?
[Response: "No formal education" or "School Certificate" or "Higher school certificate" or "Trade/Apprentice // Certificate/ Diploma" or "University degree // Higher degree" Manage on income (4) How do you manage on the income you have available?
[Response: "It is impossible" or "It is difficult all the time" or "It is difficult some of the time" or "It is not too bad" or "It is easy"]

Health conditions Number of health conditions
In the past three years, have you been diagnosed with or treated for How much BODILY pain have you had during the PAST 4 WEEKS?"None", "Very mild", "Mild", "Moderate", "Severe", "very Severe" During the PAST FOUR WEEKS, how much did PAIN interfere with your normal work (including both work outside the home and housework)?"Not at all", "A little bit", "Moderately", "Quite a bit". Extremely"

Polypharmacy b
In the past four weeks, have you taken  (2) During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours or groups?[Responses can be: "Not at all", " A little bit", "Moderately", "Quite a bit", "Extremely" During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc)?[Response to the above statement: "All of the time" or "Most of the time" or "A good bit of the time" or "some of the time" or "A little of the time" or "None of the time"] SF36 Role -Physical (2) During the past 4 weeks, have you had any of the following problems with your work (including your work outside the home and housework) or other regular daily activities as a result of your physical health?
• SF36 Role -Emotional (2) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
• Cut down on the amount of time you spent on work or other activities • Accomplished less than you would like • Didn't do work or other activities as carefully as usual [Response to the above statement: "Yes" or "No"]

Stress
Perceived stress (5) The scale assessed items in specific life domains including:

Kwok WS
b Questions listed are only based on consistent questions about medications asked from survey 2 to survey 9.Among survey 2 (1998) to survey 4 (2004), participants also reported any medications taken for various conditions for: nerves/anxiety/worries, stress (difficult coping), to help you sleep, tiredness/fatigue, depression, menopausal symptoms, high blood pressure, high cholesterol, heart problems, arthritis, diabetes or blood sugar, asthma, digestive/bowel problems, skin problems, headache, backache, other pain, any other chronic (long-term) illness or condition.In survey 5 (2007) and survey 6 (2010), participants reported all the medications in an open-ended question (i.e., writing down the names of all the medications).
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Cut down on the amount of time you spent on work or other activities • Accomplished less than you would like • Were limited in the kind of work or other activities • Had difficulty performing the work or other activities (for example it took extra effort) [Response to the above statement: "Yes" or "No"]

Table 2
(6)delines for Reporting on Latent Trajectory Studies (GRoLTS) Checklist(6)Are alternative specifications of the between-class differences in variancecovariance matrix structure considered and clearly documented?If not, was sufficient justification provided as to eliminate certain specifications from consideration?Are the total number of fitted models reported, including a one-class solution?Yes 12. Are the number of cases per class reported for each model (absolute sample size, or proportion)?Distribution of physical activity participation included in the latent class analysis (n=11,796).Data was presented in n (%) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Random seeds=100000 and rho=1 was used in the different cluster models using repeated measures latent class analysis.AIC: Akaike information criterion; BIC: Bayesian information criterion BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)